Personal Information Today’s Date Name

East Greenville Animal Hospital

Application for Employment

Personal Information Today’s Date_________________________ Name________________________________ Social Security #_____________________ Address_________________________________________________________________ City___________________________________ State___________ Zip_______________ Home Phone (____)_________________ Cell Phone (____)_______________________ If you are less than 18 years of age, please list your date of birth here: ____________

Job Interests/Desires Position(s) applying for________________________ Desired hourly wage_________________ Type of employment requested: ___Full Time ___Part Time ___Temporary ___Summer Days/Hours you are NOT available:_______________________________________________ Ideal Number of Hours per week: _________ per week Maximum Hours You Can Work: _________ per week Are you able and willing to work weekends and holidays:____________________ Date you could begin working: ______________________

Employment/Volunteering History

Please list employment and/or volunteer positions starting with the most recent position. Please account for any time periods not listed below.

1. 
   Name of Business: _______________________________________________________
   

Address: _______________________________________________________________

Phone Number: _________________Dates of Employment: ____________________ Position Held: ________________________ Job Title: _________________________

List of Duties: ___________________________________________________________

Supervisor: _______________________ Reason for Leaving: __________________

May we contact this employer? ___Yes ___No

2. 
   Name of Business: ______________________________________________________
   

Address: _______________________________________________________________

Phone Number: _________________Dates of Employment: ____________________ Position Held: ________________________ Job Title: ________________________

List of Duties: ___________________________________________________________

Supervisor: _______________________ Reason for Leaving: __________________

May we contact this employer? ___Yes ___No

3. 
   Name of Business: _______________________________________________________
   

Address: _______________________________________________________________

Phone Number: ________________Dates of Employment: _____________________ Position Held: _______________________ Job Title: _________________________

List of Duties: ___________________________________________________________

Supervisor: ______________________ Reason for Leaving: ___________________

May we contact this employer? ___Yes ___No

4. 
   Name of Business: _______________________________________________________
   

Address: _______________________________________________________________

Phone Number: ________________Dates of Employment: _____________________ Position Held: ________________________ Job Title: ________________________

List of Duties: ___________________________________________________________

Supervisor: _______________________ Reason for Leaving: ___________________

May we contact this employer? ___Yes ___No

Education

Type of Education	Name and Location	Degree, Certificate, Diploma Received	# of years attended
High School
College or University
Other

Have you ever been convicted of a felony?________________

Do you use drugs and/or alcohol or smoke on a regular basis?_______________

I certify that the information that I have provided in this application is true and correct. I understand that if any of this information is found to be false after employment is granted, employment may be dismissed. I also understand that East Greenville Animal Hospital may conduct pre-employment and/or employee drug and/or alcohol screening/testing.

_________________________________________Signature of Applicant _____________ Date


References

Business References: (Do not list relatives) Please indicate if you were employed under a different name.

Name	How you know them	Phone Number	Title	Years Known